FRBNY KYC Appendix A

CERTIFICATION OF BENEFICIAL OWNER(S)

All persons opening an account on behalf of a legal entity or updates to existing customers must provide the
following information:

1. Last Name and title of Natural Person Opening Account 2. First Name 3. Middle Initial

4. Name and type of Legal Entity for Which the Account is Being Opened

4a. Legal Entity Address 4b. City 4c. State 4d. ZIP/Postal Code

SECTION I
(To add additional individuals, see page 2)
Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above. Check here if no individual meets this definition and complete Section II.

5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

SECTION II
Please provide the following information for an individual with significant responsibility for managing or directing the
entity, including, an executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief
Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or Any other individual
who regularly performs similar functions.
16. Last Name 17. First Name 18. M.I. 19. Date of birth

(MM/DD/YYYY)

20. Address 21. City 22. State 23. ZIP/Postal Code

24. Country 25. SSN (U.S. Persons) 26. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

26a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

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I, ______________ hereby certify, to the best of my knowledge, that

the information provided above is complete and correct.
Signature: Date:
(MM/DD/YYYY)

Legal Entity Identifier (Optional)

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Additional Section 1 - Second Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth
(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

Additional Section 1 - Third Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

Additional Section 1 - Fourth Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

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Additional Section 1 - Fifth Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

Additional Section 1 - Sixth Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

Additional Section 1 - Seventh Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract
arrangement, understanding, relationship, or otherwise owns 10% or more of the equity interests of the legal entity listed
above.
5. Last Name 6. First Name 7. M.I. 8. Date of birth

(MM/DD/YYYY)

9. Address 10. City 11. State 12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons) 15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number
and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar
safeguard.

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